The Health Care System Chapter 1

Chapter 1
The Health Care System

Elsevier items and derived items © 2009 by Saunders,
an imprint of Elsevier Inc.

Pretest

True or False
1. Palliative treatment attempts to reduce symptoms but
does not cure disease.
2. In the past 30 years there has been a trend to avoid
admitting patients to the hospital if possible.
3. The first health insurance plans in the United States
were provided by the federal government.
4. The managed care movement has put pressure on
physicians to limit time spent with individual patients.
5. After graduating from medical school, a physician
spends 2-5 years in postgraduate training called an
internship.

Elsevier items and derived items © 2009 by Saunders, 2

Pretest, cont.

True or False
1. If laboratory tests are done in the medical office, there is
a specific room or area set aside for this.
2. Some medical offices use paper medical records, but
other offices store patient records electronically.
3. The physician who provides general medical care to an
adult is usually an internist or a family practitioner.
4. A group practice often consists of three or four
physicians in the same specialty.
5. In addition to standard medical treatment, only a few
patients also receive treatments that can be called
complementary medicine.


Introduction to Health and the Health Care
System

1. WHO (World Health Organization) definition
of health:
a. Absence of illness or disease
b. Individual can carry out the daily functions of life
with no difficulties and no pain


Introduction to Health and the Health Care
System, cont.

1) Western medical health care delivery based
on scientific study
2) Hippocrates (fourth century BC) credited as
the first “scientific” physician


Shift from Hospital-Based to Community-
Based Health Care

1. Designed to reduce costs of health care
2. More extensive outpatient care reduces
hospitalization costs
3. People feel better if they can avoid
hospitalization
4. Modern hospitals primarily provide acute
care and diagnostic services


Managed Care versus Patient Care:
Competing Forces

Fee-for-Service Insurance Plans
1. Traditional insurance paid for hospitalization
only
2. Each service provided was reimbursed
3. Health insurance became an increasingly
important job-related benefit in the 1950s
and 1960s
4. Cost of health insurance has increased
more rapidly than other goods and services


Government Insurance Plans

1. Federal insurance programs began in 1960s
a. Medicaid
• Began for low-income children without parental
support
• Now low-income population in general


Government Insurance Plans, cont.

– Medicare—elderly, disabled, end-stage renal
disease
– CHAMPUS—families of those in the armed
services
– Included office visits for illness but not
preventative


Managed Care

1. HMO (health maintenance organization)
movement
a. Began as attempt to reduce cost of medical
care
b. Emphasis on routine and preventative care
2. Utilization review of hospitalized patients
a. Requires reason for continued hospital stay
b. Means to shorten hospital stay


Managed Care, cont.

1. Routine care became included in traditional
insurance
2. Managed care introduced as general term
a. Care based on HMO model
b. Includes utilization review of hospitalization
c. May pay physician monthly amount (capitation)


Managed Care, cont.

– Encourages use of less expensive generic
medications
– Controls access to diagnostic tests and
additional services
– Often based on a network of health care
providers


Types of Ambulatory Care

1. Private physician offices
2. Staff HMO
3. Multispecialty group practice
4. Clinic at a hospital


Flow of Activity in an Ambulatory
Care Setting

1. Patient checks in at the front desk
2. Patient is seen by the physician
3. Diagnostic tests are ordered and/or
performed


Flow of Activity in an Ambulatory Care
Setting, cont.

(i) Follow-up
a. New appointment, appointment for diagnostic
tests, and/or referral
b. Follow-up instructions
5. Billing process is begun


Members of the Health Care Team in the
Medical Office

1. Physicians
2. Medical assistants
3. Nurses
4. Business manager


Members of the Health Care Team in the
Medical Office, cont.

i) Secretary/receptionist
ii) Insurance specialist
iii) Medical transcriptionist
iv) File clerk


Physicians and Other Primary
Care Providers

1. Physician, may be MD or DO
2. Physician's assistant (PA)
3. Nurse practitioner (NP)


Effective Teamwork

1. Teamwork is important to provide
appropriate care to patients
2. Medical assistant is an important team
member but should not overstep his or her
role
3. Effective teamwork requires good
communication


Effective Teamwork, cont.

(i) Problems should be addressed without
spending a lot of time assigning blame
(ii) Different points of view should be accepted
when trying to find solutions to problems


Parts of the Medical Office

1. Areas to receive patients, examine patients,
and perform administrative tasks
2. Must meet requirements of regulatory
agencies
a. OSHA (Occupational Safety and Health
Administration)
b. Americans with Disabilities Act
c. Local and state board of health


Waiting Room

1. Should be clean with good lighting
2. Furniture should be arranged neatly
3. Up-to-date reading material should be
available
4. Seating should be adequate
5. Colors should be muted and music should
be soft


Reception Area

1. Place where patient checks in
2. May be separated from reception area by a
glass window
a. Prevents patients from overhearing office activities
3. Appointments are made in this area or a
separate area


Examination Rooms

1. Designed for convenience of physician and
staff
2. Should be comfortable and calming for
patients
3. Reading material should be available


Laboratory

1. Must meet requirements of CLIA ’88
a. Clinical Laboratory Improvement Act of 1988
2. CLIA-waived tests are most commonly
performed
a. Tests not regulated under CLIA ’88


Medical Record Storage Area

1. Medical record storage (if paper charts are
used)
2. Contains current patient charts
3. Location should be accessible to business
area
4. Records of inactive patients may be stored
elsewhere


Business Area or Business Office

1. May connect to reception area or be
separate room
2. Place for entering patient charges and
payments and billing


Billing and Insurance

1. Billing and insurance may be done in
several ways:
a. In the office
b. In a central billing office for several medical
facilities
c. Contracted to an outside firm


Additional Areas

1. Physician's private office
a. Often a reflection of the physician's
personal taste
b. For meeting privately with patients, patient's
family, and visitors
2. Staff lunch and break room


Additional Areas, cont.

1. Treatment/diagnostic test room
a. Best if located in separate room
b. Should be fully stocked for procedures
(iv) Special procedures room or surgery room
a. Depends on specialty of the office


Medical Specialties

1. Usually have their own residency programs
2. Subspecialties require additional training
(fellowship)
3. Based on patient age, body system, and/or
type of treatment


Medical Specialties, cont.

(i) May focus on medical treatment
a. Example: neurology
iii) May focus on surgical treatment
a. Example: neurologic surgery (neurosurgery)
v. May include both medical and surgical
treatment
a. Example: ophthalmology


Primary Care

1. Provides general care for patients
a. Internal medicine—adults
b. Pediatrics—children
c. Family medicine—all ages
d. Sometimes OB/GYN—female adults


Osteopathy

1. Takes a holistic approach to primary care
2. DO (doctor of osteopathy) licensed by the
state to practice medicine
3. Manipulates bones and muscles to balance
the body


Podiatry

1. Treatment of the foot and ankle
2. Both medical and surgical treatment
provided


Chiropractic

1. Spinal manipulation to treat musculoskeletal
disorders
2. Practitioner is licensed by the state
3. More limited role than an osteopathic
physician


Practice Types

Solo Practice
2. Limited in size
3. Medical assistant usually responsible for
administrative and clinical duties
4. Physicians share evening and weekend
responsibility with other physicians


Practice Types, cont.

Group Practice
2. Several physicians share office space,
personnel, equipment, etc.
3. Medical assistants usually specialize
a. Administrative
b. Clinical
3. Patients can be seen by any physician for
urgent treatment



Group Practice, cont.
(ii) Types of group practice
a. Single medical specialty
b. Multispecialty (several specialties within
one facility)
c. Satellite offices in two or more locations



Clinic

1. Traditionally, an ambulatory care facility that
provides free or low-cost care
2. Physicians employed by the clinic
a. May be physicians (MDs)
b. May be in a residency program (residents)


Complementary and
Traditional Medicine

1. Used in addition to standard therapies
2. If studied scientifically, may be widely
accepted (e.g., acupuncture)
3. Patients must often cover costs


Posttest

True or False
1. In order to be hospitalized, a patient’s condition must be
very unstable or require regulation of therapy.
2. Managed care insurance is another name for
fee-for-service insurance.
3. A nurse practitioner manages routine patient care and
can write prescriptions in most states.
4. When a patient enters the office, he or she is
immediately taken to a treatment room.
5. The government agency that provides for health and
safety in the workplace is CLIA.


Posttest, cont.

True or False
6. Medical records for all patients who have been seen in
the past 10 years are kept in the medical office.
7. The medical office may have a special room just for
treatments or procedures.
8. An osteopathic physician (DO) provides primary care and
has the same legal status as a physician with an MD
degree.
9. The physician who specializes in diseases of the nervous
system is a neurologist.
10. Acupuncture is considered to be a standard medical
treatment.


The Health Care System Chapter 1

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